In CMS 1500 form
The other ID number of the referring provider, ordering provider, or other source should be reported in 17a in the shaded area. The qualifier indicating what the number represents should be reported in the qualifier field to the immediate right of 17a. The NUCC defines the following qualifiers, since they are the same as those used in the electronic 837 Professional 4010A1:
• 0B – State license number
• 1B – Blue Shield provider number
• 1C – Medicare provider number
• 1D – Medicaid provider number
• 1G – Provider UPIN number
• 1H – CHAMPUS identification number
• EI – Employer’s identification number
• G2 – Provider commercial number
• LU – Location number
• N5 – Provider plan network identification number
• SY – Social Security number (The Social Security number may not be used for Medicare)
• X5 – State industrial accident provider number
• ZZ – Provider taxonomy – A list of the valid Taxonomy codes
On UB 04 form
Field – 43. Revenue code Description
Enter a brief description that corresponds to the Revenue Code in column 42.List applicable NDC if location 44 is a J code.
Report the N4 qualifier in the first two (2) positions, left justified, followed immediately by the 11 character NDC number. Immediately following the last character of the NDC (no space) the Unit of Measurement Qualifier immediately followed by the quantity with a floating decimal with a limit of 3 characters to the right of the decimal point.
Unit of Measurement:
F2 – International Unit
GR – Gram ML – Milliliter
UN – Unit
To report more than one NDC per HCPC use the NDC attachment form. Enter “Total Charges” after the last description in this column to correspond with the total of all charges amount in column 47.
Field 76. Attending Provider Name and Identifiers
Enter NPI of individual in charge of patient care. If UPIN number is entered, qualifier must be 1G. Enter the last and first name below
Claim Filing Indicator Code
The Claim Filing Indicator Code identifies the type of claim being filed. BCBSNC requires that the first instance of this code (2000B, SBR09) within the 2000B looping structure be either a value of BL (Blue Cross/Blue Shield) or ZZ (Mutually Defined – for subscribers covered under the State Employee Health Plan).
P015 For the first instance of SBR09 within this Hierarchical Level (HL), use a value of BL (Blue Cross/Blue Shield) , except for subscribers covered by State Health Employee Plan, use a value of “ZZ” (Mutually Defined)
BCBSNC Business Edits for the 837 Health Care Claim
The following proprietary error codes and messages are returned via the Claims Audit Report. The Claims Audit Report can be accessed from your electronic mailbox for direct submitters, or online, via Blue e (https://providers.bcbsnc.com/providers/login.faces ) – see the 837 Claim Denial Listing.
Important Note: These error codes are not returned for Medicare Advantage or Medicare Supplemental claims. Error Code* Explanation Message 837 Professional Cross-references4
P004 When Other Insured’s Entity Code (NM101) = IL, Entity Qualifier must equal ‘1’. 2330A, Other Subscriber Name, NM102
P005 Newborn charges should not be filed on the Parent’s claim. They should be filed separately under the baby’s name and Member ID. 2400, Professional Service, SV101:2
P006 Member ID must be valid. 2010BA, Subscriber Name, NM109
P015 The first occurrence of Claim Filing Indicator must be BL or ZZ. 2000B, Subscriber Information, SBR09
P018 Member ID not valid for Date of Service (DOS). 2010BA, Patient Name, NM109
P022 Provider NPI not registered with BCBSNC. Please contact Network Management at 1-800-777-1643 to resolve this matter. 2010AA, Provider ID, NM109
P026 Billing Provider Secondary ID Qualifier must equal G2 and/or Billing Provider Secondary ID must be valid for Medicaid submitted claims. 2010BB, Provider ID, REF02
P027 Medicare Advantage/Medicare Supplement Member ID is invalid. Please correct and resubmit. 2010BA, Member ID, NM109
P028 Negative Service Line Paid Amount invalid. 2430, Service Line Paid Amount, SVD02
HCFA 1500 (08-05) Professional Claim Form (for enumerated providers)
HCFA 1500 Data Element HCFA 1500 Field/Box
Billing Provider NPI Field 33a
Billing Provider TIN Field 25
Billing Health Care Provider Taxonomy Field 33b (Qualifier ZZ)
Referring/Supervising Physician NPI Field 17b
Rendering Physician NPI Field 24j
Important: Make sure that your claim software supports the 08-05 version of the 1500 claim form. Reference the 1500 Instruction Manual at Nucc.org for specific details on completing this form.
UB-04 Paper Institutional Claim Form (for enumerated providers)
UB04 Data Element UB04 Field Locator
Billing Provider NPI Form Locator 56
Billing Provider TIN Form Locator 05
Billing Health Care Provider Taxonomy Form Locator 81 (Qualifier B3)
Attending Provider NPI Form Locator 76
Operating Physician NPI Form Locator 77
Other Provider NPI Form Locator 78-79 (With Qualifier: DN Referring, ZZ Other Operating Physician, 82 Rendering and NPI)
See definitions in the UB-04 Data Specifications Manual available at Nubc.org. Any changes to our NPI policy will be preceded with communications to physicians and other health care professionals, organizations and trading partners. Such communications will announce when we will no longer accept HIPAA transactions which do not contain a valid NPI.
ID NUMBER OF REFERRING PROVIDER, ORDERING PROVIDER OR OTHER SOURCE
Enter the qualifier in the first shaded box of 17a indicating what the number reported in the second shaded box of 17a represents. Atypical providers should report the IHCP LPI provider number in the second box of 17a. Health care providers should report the taxonomy code in the second box of 17a. The qualifier is required when entering the IHCP LPI provider number or taxonomy. Qualifiers to report to IHCP.
1D and G2 are the qualifiers that apply to the IHCP provider number, also called the LPI for the atypical non-health care providers. The LPI includes nine numeric characters and one alpha character for the service location.
ZZ and PXC are the qualifiers that apply to the provider taxonomy code. The taxonomy code includes 10 alphanumeric characters. Taxonomy may be needed to establish a one-to-one NPI/LPI match if the provider has multiple locations. Required when applicable and for any waiver-related services. (Required if applicable.)
RENDERING ID QUALIFIER Enter the qualifier indicating what the number reported in the shaded area of 24J represents – 1D or G2 for IHCP LPI rendering provider number, or ZZ or PXC for rendering provider taxonomy codes. (Required, if applicable.)
1D and G2 are the qualifiers that apply to the IHCP provider number (LPI) for atypical non-health care providers. The LPI includes nine numeric characters. Atypical providers (for example, certain transportation and waiver service providers) are required to submit their LPIs.
ZZ and PXC are the qualifiers that apply to the provider taxonomy code. The taxonomy code includes 10 alphanumeric characters. The taxonomy code may be required for a one-to-one match.
RENDERING PROVIDER ID Enter the LPI if entering the 1D or G2 qualifier in 24I or the taxonomy if entering the ZZ or PXC qualifier in 24I for the rendering provider 1D or G2. (Required, if applicable.) LPI – The entire nine-digit LPI must be used. If billing for case management, the case manager’s number must be entered here. Taxonomy – Enter the taxonomy code of the rendering provider. (Optional unless required for a one-to-one match.)
BILLING PROVIDERQUALIFIER AND ID NUMBER
Health care providers may enter a billing provider qualifier of ZZ or PXC and taxonomy code. Taxonomy may be needed to establish a one-to-one NPI/LPI match if the provider has multiple locations.
If the billing provider is an atypical provider, enter the qualifier 1D or G2 and the LPI. (Required)